Camp Conservation Registration Forms
Newberry Soil And Water Conservation District
USDA Service Center, 719 Kendall Road, Newberry, SC 29108
Phone:803-276-1978 Ext. 3, Fax: 803-276-7887
*2008 NOTICE* If your computer settings do not find these forms to be
"Printer Friendly" printing from the web page...
Then you may download the .pdf version for printout here ...
2008 Camp Application.pdfYOU MAY PRINT THESE FORMS FROM THIS WEB PAGE AND SUBMIT FOR APPLICATION
NOTE:
IF SUBMITTING FORMS FROM WEBSITE PLEASE PRINT AND SIGN "RULES ACKNOWLEDGE FORM" ON "ABOUT" PAGE AS WELL!
Registration Form
Camper's Name:
________________________________________________________________
Mailing Address:
________________________________________________________________
City:
________________________________
State:____________________Zip:__________________
E-mail adrress
:______________________________________@____________________________________
Age: 9 10 11 12
How many years have you attended CAMP CONSERVATION ? 1 2 3 4 5
Sex: Male Female
School: __________________________________________________________________________
Mother's Name:_________________________________________________________________
or Guardian
Home Address: __________________________________________________________________________
City: ____________________________________ State:________________Zip:_________________
Home Phone # (________) _______-___________ Cell Phone # (________) _______-____________
Work Phone # (________) ________-__________ Pager # (________) _______-___________
Employer's Name: ____________________________________________________________________________
Work Address: ___________________________________________________________________________
City: _________________________________ State: ______________ Zip: __________________
Father's Name:____________________________________________________
Home Address: __________________________________________________________________________
City: _______________________________ State: ______________Zip:____________________
Home Phone # (______) _______-_________ Cell Phone # (______) _______-__________
Work Phone # (______) _______-__________ Pager # (______) _______-__________
Employer's Name: __________________________________________________
Work Address: ___________________________________________________
City: ________________________________ State: _______________ Zip: _____________
Other CONTACT INFORMATION: other than the names and numbers listed above ...
Please provide additional persons to contact should you not be available.
Name: ____________________________________Relationship to child:______________________________
Phone #: (______) _______-_________ CELL Phone: (______) ______-__________
Name: ____________________________________Relationship to child:__________________________________
Phone #: (______) _______-_________ CELL Phone: (______) ______-__________
EMERGENCY MEDICAL RELEASE FORM Student's Name:
_________________________________________________________________
Social Security Number: ________-_______-___________ Birthdate: _______/_______/_______
Birthplace: ________________________ Mother's Maiden name: _________________________
Is the child covered under a medical insurance plan? YES NO
Name of family health care insurance company:_________________________________________
Name of Primary Policy Holder:______________________________________________________
Policy Number:__________________________________________________
Medical History
A. List all medications participant is currently taking:
___________________________________________________________
B. List all medical conditions currently under treatment:_________________________________________________________
C. Has the participant lost a paired organ such as a kidney or an eye? If YES, please describe
:__________________________________________________
D. Is the participant allergic to any medications? If YES, please list:___________________________________________________________
E. Does the participant have any known life threatening allergic reactions:
(bee or wasp stings, p-nut allergy, etc.) YES NO
Please list:
_________________________________________________________________________________
F. Date of last Tetanus Immunization: _______/________/________G. Additional Information:_______________________________________________________________________
(Attach additional page if necessary.)
By signing this form you hereby grant permission for your child to be treated in case of a medical emergency. The Newberry County hospital, police, fire and rescue departments are on alert should they be needed at any time. Two-way radio and cell phone communications are used during camp.
The law requires the parental permission be obtained for operative procedures on minors in the State of South Carolina. The following consent form should be signed by both parents or legal guardian so that such procedures may be promptly carried out, and so that no unnecessary delays will occur with operative procedures.
However, no operation will be performed, except emergency, without parents/guardian being contacted and fully informed first.
I give permission for such diagnostic, therapeutic, and operative procedures as may be deemed necessary for my son / daughter. I authorize the release of any medical information to process insurance claims and request payment benefits to the physicians or suppliers for services described. I further understand that I will be financially responsible for payment in full for any charges incurred.
I understand that the registration fee for this program does not include any form of insurance coverage. I acknowledge that I choose to release and hold harmless the Camp Conservation Program, Newberry Soil and Water Conservation District, Newberry County, The City of Newberry, NRCS, DNR, or any other businesses or persons, or associates from liability, expenses, damages, losses or costs (including attorney's fee) incurred as a result of the above named child during his/her participation in this program.
Signature Mother:________________________________ Date: _______\________\ 20____
Signature Father:_______________________________________ Date: _______\________\ 20_____
Signature of Guardian:_____________________________________ Date: _______\________\ 20____
NOTE- Please also print and sign the RULES ACKNOWLEDGEMENT form ...located on the ABOUT page! THANK YOU!